STANLEY A. BOONE, Magistrate Judge.
Plaintiff Christopher Segura ("Plaintiff") seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying his application for disability benefits pursuant to the Social Security Act. The matter is currently before the Court on the parties' briefs, which were submitted, without oral argument, to Magistrate Judge Stanley A. Boone.
Plaintiff suffers from asthma, schizoaffective disorder, alcoholism, and partial hearing loss. For the reasons set forth below, Plaintiff's Social Security appeal shall be denied.
Plaintiff protectively filed an application for a period of disability and disability insurance benefits on October 6, 2009, and a Title XVI application for supplemental security income on October 7, 2009. (AR 121, 156.) Plaintiff's applications were initially denied on June 30, 2010, and denied upon reconsideration on September 3, 2010. (AR 66-70, 73-77) Plaintiff requested and received a hearing before Administrative Law Judge Trevor Skarda ("the ALJ"). Plaintiff appeared for a hearing on August 16, 2011. (AR 33-58.) On September 19, 2011, the ALJ found that Plaintiff was not disabled. (AR 15-27.) The Appeals Council denied Plaintiff's request for review on April 16, 2013. (AR 1-3.)
Plaintiff appeared for a hearing on August 16, 2011, and was represented by counsel, Jeffrey Milam. (AR 35.) Plaintiff was born on October 11, 1965, received his GED, and took some college classes in 2007. (AR 37, 38, 49-50.) Plaintiff has worked in the past and has left jobs without letting the boss know on two occasions. (AR 40.) In 1998, Plaintiff worked as a cashier for Orchard Supply. (AR 54.) Plaintiff also worked as a car driver for auction. (AR 53.) Plaintiff applied for Social Security benefits once before in 2006. (AR 45.) Plaintiff thinks that he might be able to work part time depending on the job. (AR 41.)
Plaintiff has been homeless for seven years. (AR 38.) He became homeless when the rent on his apartment was raised and his father, who was helping him, decided to give up the lease. (AR 50.) For the first three years, Plaintiff lived in his car and since then has lived at the Modesto Gospel Mission and Salvation Army shelter. (AR 38.) Currently, Plaintiff is residing at the Salvation Army shelter. (AR 37.) At the Salvation Army, Plaintiff has been sleeping in the lobby because he has a snoring problem that bothers the other residents. (AR 39.) Plaintiff keeps to himself so he does not bother anyone or get into anything. (AR 39-40.)
Plaintiff has irritable bowel syndrome and on a bad day might need to use the bathroom four times for up to fifteen minutes at a time. (AR 41-42.) Plaintiff has bad days four days a week. (AR 41.) Plaintiff has difficulty hearing, even when he wears his hearing aids. (AR 42.) Plaintiff's current hearing aids are working pretty well. (AR 43.) Plaintiff has lower back problems and if he sits too long his hips get really sore. (AR 43.) Plaintiff has not received any treatment, but takes Naproxen when he feels the need. (AR 43.)
Plaintiff takes Zoloft for his schizophrenia. (AR 43.) Plaintiff's schizophrenia makes him anxious and causes issues dealing with people. (AR 44.) Plaintiff takes his medication in the evening because he gets anxiety when he goes to the shelter. (AR 52.) His anxiety is worse in the fall and winter because he has to stand in line and does not know if he will get into the shelter. (AR 52.)
Plaintiff has had difficulty working because his employers ask him to do more and more stuff and it becomes confusing. (AR 44.) Plaintiff has trouble focusing when he is under a lot of pressure. (AR 44.) His confusion started about ten years ago. (AR 45.) Plaintiff has trouble concentrating and tends to drift off after about half an hour. (AR 45.) Plaintiff hears voices when he is under a lot of stress, but that has not happened in a while. (AR 46.) Plaintiff experiences stress when he has to deal with people expecting him to accomplish a lot of things or expecting him to be or perform a certain way. (AR 46.) Plaintiff might feel pressure if he had to go to work on time and stay at work eight hours a day, five days a week, depending on how he had to get to work and what was expected of him when he got there. (AR 46-47.)
On a normal day, Plaintiff leaves the shelter and goes downtown for coffee and donuts which he pays for with food stamps. (AR 47) Plaintiff then goes to the library and uses the internet or reads books. (AR 47.) Plaintiff will have to stop because he has problems concentrating. (AR 47.) Plaintiff walks about a half mile to the Salvation Army for lunch. (AR 47-48.) After lunch, Plaintiff goes back to the library. (AR 48.) Plaintiff goes back to the Salvation Army for dinner. (AR 48.)
Plaintiff does not have problems with drugs or alcohol and has not had a problem with illegal drugs. (AR 50.) Plaintiff worked at Walmart in 2002, and before that worked at temporary jobs. (AR 50-51.) Plaintiff worked as a bell ringer for the Salvation Army the prior Christmas, but they did not hire him. (AR 51.) He did not bring in enough money and standing hurt his back. (AR 51-52.) Plaintiff stopped working in July 2007 when the company he was working for moved to Turlock. (AR 52-53.) After that he was unable to find any work. (AR 53.)
A vocational expert ("VE"), Harry Cynowa testified at the hearing. (AR 53-57.) The VE described Plaintiff's past work experience as cashier, unskilled, light. (AR 54.)
The ALJ presented a hypothetical of a person of Plaintiff's age, education, and work experience with no exertional limitations. (AR 55.) The individual must avoid concentrated exposure to irritants, such as fumes, odors, dust, gases and poorly ventilated areas; limited to occupations that do not require fine hearing capability or frequent telephone communication or frequent verbal communication; and simple routine and repetitive tasks. (AR 55.) The work must be low-stress, no more than occasional decision making or occasional changes in the work setting. (AR 55.) Work may be around co-workers throughout the day with only occasional interaction with co-workers, and no communication with the general public. (AR 55.)
The VE opined that this individual would be able to work as a hand packager, 6,000 positions in California and greater than 100,000 in the national economy; small products assembler, 6,000 positions statewide and greater than 100,000 nationally; or a visual inspector, 2,500 positions locally and greater than 80,000 nationally. (AR 55-56.)
The VE opined that the threshold for off-task behavior would between 10 and 15 percent, and at 20 percent all work would be precluded. (AR 56.) If an individual was off task up to a fifth of the work day all work would be precluded. (AR 56.)
The VE was presented with a hypothetical of an individual who must be isolated and could have no more than occasional supervision. (AR 56.) The VE opined that there would be no jobs for this individual. (AR 56.)
The ALJ found that Plaintiff had the following severe impairments: asthma, schizoaffective disorder, alcoholism, and partial hearing loss. (AR 20.) Plaintiff's impairments, alone and in combination, do not meet or medically equal the severity of one of the listed impairments. (AR 21.) Plaintiff has the residual functional capacity to perform a full range of work at all exertional levels, with the following nonexertional limitations: he must avoid concentrated exposure to irritants such as fumes, odors, dust, gases, or poorly ventilated areas; limited to occupations that do not require fine hearing capability, frequent verbal communications, or frequent telephone communication; is able to perform simple, routine, repetitive tasks that require only occasional decision making and changes in the work setting; and can be around coworkers throughout the day, but have only occasional interaction with coworkers and no jobs where an essential element of the job requires communications with the general public. (AR 22.) There are significant jobs that exist in the national economy that Plaintiff can perform. (AR 26.) Plaintiff is not disabled. (AR 27.)
Congress has provided that an individual may obtain judicial review of any final decision of the Commissioner of Social Security regarding entitlement to benefits. 42 U.S.C. § 405(g). In reviewing findings of fact in respect to the denial of benefits, this court "reviews the Commissioner's final decision for substantial evidence, and the Commissioner's decision will be disturbed only if it is not supported by substantial evidence or is based on legal error."
"[A] reviewing court must consider the entire record as a whole and may not affirm simply by isolating a specific quantum of supporting evidence."
Plaintiff argues that the ALJ erred by failing to properly weigh the opinions of Dr. Castillo, Dr. Garcia, and Dr. Fair and by failing to consider Plaintiff's irritable bowel syndrome at step two. (Plaintiff's Opening Brief at 7, ECF No. 13.) Defendant counters that the ALJ properly considered the medical evidence, including the opinions of the doctors and the effects of all of Plaintiff's severe impairments. (Defendant's Opposition to Plaintiff's Opening Brief 6-9, ECF No. 16.) Plaintiff replies that the ALJ failed to conclude what level of weight should be given to Dr. Castillo's opinion or provide specific and legitimate reasons for rejecting the opinion of Dr. Castillo and the opinions of Dr. Garcia and Dr. Fair do not constitute substantial evidence to justify rejecting the opinion of Dr. Castillo. (Plaintiff's Reply Brief 2-4, ECF No. 17.)
Plaintiff contends that the ALJ failed to give sufficient weight to the opinion of Dr. Castillo, and did not indicate the weight given to or provide specific and legitimate reasons for rejecting the opinion. Defendant argues that Plaintiff provided sufficient reasons to reject the opinion of Dr. Castillo which was not supported by medical evidence in the record or Plaintiff's daily activities.
The weight to be given to medical opinions depends upon whether the opinion is proffered by a treating, examining, or non-examining professional.
"In order to reject an examining physician's opinion, `the ALJ has to give clear and convincing reasons. . . . Even if contradicted by another doctor, the opinion of an examining doctor can be rejected only for specific and legitimate reasons that are supported by substantial evidence in the record.'"
The contrary opinion of a non-examining expert is not sufficient by itself to constitute a specific, legitimate reason for rejecting a treating or examining physician's opinion, but "it may constitute substantial evidence when it is consistent with other independent evidence in the record."
Dr. Castillo found that Plaintiff's social interaction was normal. (AR 228.) He was oriented to month, day of the week, year and city of evaluation. (AR 228.) Dr. Castillo also found that Plaintiff's attention span was fair, he was not easily distracted and needed no structure from the examiner during the exam, and his thought processes were organized. (AR 228.) Plaintiff's memory was found to be poor, but he was able to recall adequate details of his personal history. (AR 228.)
Plaintiff was able to recall seven digits forward and three digits backwards. (AR 228.) Plaintiff could not multiply 5 × $.25 accurately, however when asked what 5 quarters were he was able to respond appropriately with $1.25. (AR 228.) When asked to spell "world" backwards Plaintiff stated "dlorw" and was only able to recite five days of the week in reverse. (AR 228.) Plaintiff was unable to perform serial three subtractions beginning from 25. (AR 228.) Plaintiff was unable to draw a clock showing the time at ten minutes after eleven. (AR 228.) Plaintiff could not describe the similarity between an apple and an orange, or interpret the proverb, "don't cry over spilled milk." (AR 228.) Plaintiff described his mood as being depressed, however the evaluator found his mood to be euthymic.
Based on his observations, Dr. Castillo strongly suspected that Plaintiff had schizophrenia. (AR 229.) Plaintiff reported having hallucinations, was delusional about the movie Avatar affecting the world we live in, and exhibited disorganized thinking. (AR 229.) Plaintiff showed dysfunction in interpersonal relationships, work and self-care. (AR 229.) Dr. Castillo stated that Plaintiff did fairly well on the examination, but he still considered Plaintiff to have mental limitations. (AR 229.)
Dr. Castillo found that Plaintiff was able to socially interact with others at an age-appropriate level, understand instructions, sustain an ordinary routine without sustained supervision, complete simple tasks, and avoid normal hazards. (AR 229.) Plaintiff had marked limitation in his ability to complete detailed or complex tasks and to concentrate for at least two-hour increments at a time in order to maintain a regular work schedule. (AR 229.) Plaintiff is unable to handle funds. (AR 229.)
The ALJ found that the record fails to document any objective clinical findings establishing that Plaintiff's medically determinable impairments would prevent him from performing work in light of the reports of the treating and examining practitioners and the examination findings. (AR 23.) Dr. Castillo found Plaintiff generally oriented in time, place, and city, had good recall, and his thought processes were organized. (AR 23.) The ALJ opined that these findings indicate that Plaintiff's complaints are not fully substantiated by objective medical conclusions and Plaintiff's symptoms may not be as limiting as he alleged. (AR 23.)
While Plaintiff argues that his credibility is not at issue in this appeal, the ALJ based his finding on the fact that Plaintiff's symptoms are not as severe as Plaintiff alleged. The ALJ found that Plaintiff has been less than truthful about his alcohol abuse. (AR 23.) The ALJ provided a clear and convincing reason to find Plaintiff not credible and there is substantial evidence in the record to support the finding. Despite being diagnosed with alcoholism, Plaintiff has consistently denied the use of alcohol.
The ALJ considered that there is no indication that Plaintiff has ever been hospitalized due to his mental impairment and had been no significant increase or changes to Plaintiff's prescribed medications that would be indicative of an uncontrolled condition and Plaintiff does not describe any medication side effects that would prevent him from substantial gainful activity. (AR 23-24.) This finding is consistent with the medical record which shows that Plaintiff was stable on his medication and reported no side effects.
The ALJ considered that Plaintiff has admitted certain abilities which indicate that he is not as limited to the extent that would be expected given the complaints of disabling symptoms and limitations. (AR 24.) The ALJ found that the overall evidence suggests that Plaintiff has the ability to care for himself and maintain a home. (AR 24.) There is support in the record based on Plaintiff's stated abilities; he is able to wash dishes, vacuum, sweep, and do laundry (AR 229); and his daily activities as discussed below.
The ALJ also found that Plaintiff's daily activities are not inconsistent with the performance of many basic work activities. (AR 24.) Substantial evidence in the record supports this finding. Plaintiff is able to use public transportation by himself and walks several miles a day. (AR 47-48, 153, 229.) Plaintiff goes to the library daily and while at the library Plaintiff reads or uses the internet. (AR 47.) Plaintiff's hobbies are reading novels and surfing the internet. (AR 145, 152, 229.) Plaintiff participates in these activities every day and is able to do them fairly well. (AR 152.) Plaintiff indicates that he is able to follow written instructions if they are not complicated or too lengthy. (AR 153.) The ALJ properly considered that Plaintiff's daily activities were inconsistent with the opinion of Dr. Castillo that Plaintiff was unable to concentrate for at least two-hour increments at a time in order to maintain a regular work schedule.
The ALJ stated that he considered the opinion of Dr. Castillo, as it was based upon a thorough review of the evidence and familiarity with Social Security Rules and Regulations and legal standards. (AR 25.) Although Dr. Castillo found Plaintiff had moderate mental impairments, the ALJ found that Plaintiff's medical condition indicates less severe limitations. (AR 25.) There is substantial evidence in the medical record to indicate that Plaintiff's symptoms were not as severe as stated by Dr. Castillo. While Dr. Castillo found Plaintiff to be delusional, the medical record is devoid of any other indication of such a condition. (AR 331.)
Further, Dr. Castillo's opinion was based on Plaintiff's statement that he hears voices. (AR 229.) The record demonstrates that Plaintiff has slight schizoaffective issues which are well controlled with medication. (AR 199, 201, 205, 210, 247, 330, 385.) Other than Plaintiff's statement in Dr. Castillo's report, the only record of Plaintiff hearing voices in the medical record is on September 18, 2008, when the record states that Plaintiff saw a counselor and admitted to having a conversation with himself. (AR 208.) The record of this visit on September 9, 2008, states that Plaintiff "admits to hearing voices but then says he is not sure." (AR 209.) The ALJ properly considered that the medical record did not support the stated limitations.
Plaintiff contends that since the ALJ states that Dr. Castillo did not have an opportunity to review additional medical evidence submitted after the evaluation or listen to Plaintiff's sworn testimony and observe his demeanor (AR 25), the ALJ was required to further develop the record. The ALJ has a duty to further develop the record where the evidence is ambiguous or the ALJ finds that the record is inadequate to allow for proper evaluation of the evidence.
The ALJ provided legitimate and specific reasons to give little weight to the opinion of Dr. Castillo which are supported by substantial evidence in the record.
Plaintiff contends that the ALJ improperly gave significant weight to the opinions of Dr. Garcia and Dr. Fair. (ECF No. 13 at 12.) Defendant counters that the ALJ properly relied on the opinions of the agency physicians and gave specific and legitimate reasons for doing so. (ECF No. 16.) Plaintiff replies that Dr. Garcia and Dr. Fair did not have anything more than the opinions of Dr. Castillo and Dr. Solorza to rely upon and since they are not supported by independent clinical evidence their opinions could not constitute substantial evidence. (ECF No. 17 at 5.)
The ALJ gave significant weight to the opinions of Dr. Garcia and Dr. Fair as they were based upon a thorough review of the evidence and familiarity with the Social Security Rules and Regulations and legal standards. (AR 25, 26.) Further, the ALJ found they were "well-supported by the medical evidence, including the claimant's medical history and clinical and objective signs and findings as well as detailed treatment notes, which provides a reasonable basis for claimant's chronic symptoms and resulting limitations. Moreover, the opinions are not inconsistent with other substantial evidence of record. (AR 25, 26.)
Dr. Garcia completed a Psychiatric Review Technique and Mental Residual Functional Capacity Assessment on June 23, 2010. (AR 258-68, 269-271.) Dr. Garcia found that Plaintiff had a medically determinable impairment present. (AR 260.) Plaintiff had mild restrictions of daily living activities, and difficulties in maintaining social functioning; moderate difficulties in maintaining concentration, persistence, or pace; and no repeated episodes of decompensation. (AR 266.) Plaintiff had moderately limited ability to understand and remember detailed instructions. (AR 269.)
Dr. Fair completed a case analysis on September 3, 2010. (AR 336.) Dr. Fair found that Plaintiff has received no formal mental health treatment and there is no evidence of a mental health referral. (AR 336.) His primary care provider completed the Mental Health Disorder form, however, he did not provide any progress notes and he is not a mental health professional. (AR 336.) Dr. Fair affirmed the prior decision of June 23, 2010. (AR 336.)
While Plaintiff argues that Dr. Garcia's diagnosis for Plaintiff was unclear, that is consistent with the record as Dr. Castillo strongly suspected that Plaintiff had schizophrenia (AR 229); Mr. Sandoval reported that Plaintiff appears to have psychiatric problems but it is unclear what they are (AR 209); and Dr. Lopez-Solorza alternately reported Plaintiff's condition as schizoaffective disorder, schizophrenia, depression, mild depressive disorder, and seasonal affective disorder (AR 199, 200, 202, 204, 205, 208, 210, 212, 246, 247, 385, 386, 387.) All the physicians recognized that Plaintiff had a mental disorder and the ALJ found that Plaintiff had a severe mental impairment — schizoaffective disorder. (AR 20.) The issue addressed by Dr. Garcia was the extent of Plaintiff's impairments based upon that disorder regardless of the label.
Further, although Plaintiff argues that Dr. Garcia had only the opinion of Dr. Castillo to support his findings, the record shows that Dr. Garcia reviewed all three of Plaintiff's files. (AR 256.) Dr. Garcia found that Plaintiff had been diagnosed with schizophrenia upon a one-time consultative examination and he was uncomfortable with this. (AR 256.) While Dr. Garcia stated that they should double their efforts to contact any treating psychiatrist or facility where Plaintiff received treatment, there was no such psychiatrist or facility. Plaintiff was receiving treatment only from Dr. Lopez-Solorza and those records were part of the file reviewed by Dr. Garcia.
Plaintiff also contends that Dr. Fair admitted that he did not have all information available to other medical sources. (ECF No. 17 at 5.) The Court assumes this is in reference to Dr. Fair's statement that Dr. Lopez-Solorza did not provide progress notes. (AR 336.) However, a review of the medical record shows there was one visit with Dr. Lopez-Solorza from the date of Dr. Garcia's June 23, 2010 to the date of Dr. Fair's review. Plaintiff was seen on July 15, 2010. At this visit, Plaintiff was disheveled, his affect was flat, and Dr. Lopez-Solorza's diagnosis was"? Schizoeffective D/O." This is consistent with Plaintiff's other visits which do not show clinical findings indicative of the degree of limitations found by Dr. Lopez-Solorza.
As discussed above, the ALJ provided legitimate and specific reasons to give little weight to the opinion of Dr. Castillo which are supported by substantial evidence in the record. The ALJ also found the opinion of Dr. Lopez-Solorza was not supported by medical test results or objective medical observations to support his findings. (AR 24.) Reviewing the medical record, Dr. Lopez-Solorza's notes show that Plaintiff presented with a flat affect and at times had poor eye contact and seemed internally preoccupied. (AR 199, 201, 202, 210, 208, 245, 246, 328, 385, 386, 387.) The record also shows that Plaintiff was talkative, spoke intelligently, and his mental issues were stable on his medication. (AR 202, 232, 363.) The ALJ also considered Plaintiff's activities which did not indicate the degree of impairment found by Dr. Lopez-Solorza. Where, as here, the evidence is subject to more than one rational interpretation, the ALJ's decision must be upheld.
The ALJ appropriately accorded weight to the opinions of Dr. Garcia and Dr. Fair.
Finally, Plaintiff contends that the ALJ erred by failing to consider Plaintiff's irritable bowel syndrome at step two. (ECF No. 13 at 14.) Defendant counters that, since the ALJ found severe impairments, he merely needed to consider the functional effects of all his impairments, not whether the impairment was severe or non-severe. (ECF No. 16 at 9.)
At step two, the ALJ stated that he "took into consideration all the claimant's other diagnosed conditions and finds that there is minimal clinical evidence to corroborate or support any finding of significant vocational impact related to them." (AR 21.) The mere existence of an impairment is insufficient proof of a disability.
While Plaintiff testified to having symptoms four times per week, the medical record is devoid of any complaints to his physician related to his irritable bowel symptoms. The medical record demonstrates that Plaintiff's irritable bowel syndrome was stable and well controlled by his medication. (AR 200, 205, 385, 386.)
Even if the ALJ had failed to address Plaintiff's irritable bowel syndrome at step two, any such error would be harmless as the ALJ considered the limitations posed by Plaintiff's irritable bowel syndrome.
Based on the foregoing, the Court finds that the ALJ's decision is supported by substantial evidence. Accordingly,
IT IS HEREBY ORDERED that Plaintiff's appeal from the decision of the Commissioner of Social Security is DENIED. It is FURTHER ORDERED that judgment be entered in favor of Defendant Commissioner of Social Security and against Plaintiff Christopher Segura. The Clerk of the Court is directed to CLOSE this action.